Story from the Field

Push-Method Distribution of H1N1 Vaccinations by Public Health District at Major Metro Atlanta Mall

Description of Issue(s):

H1N1 influenza was present in pandemic levels through out the United States and our local community (Gwinnett, Newton and Rockdale Counties in Georgia). An initial national shortage of vaccine lead the CDC to limit vaccinations to certain target populations. The vaccine shortage at our district level required us to limit vaccinations to CDC target groups and only offer the vaccine in our clinics. H1N1 vaccine was available in Gwinnett, Newton, and Rockdale, County health department clinics throughout the week, but that was not effectively reaching the overall community that we serve (approximately 1 million people).

Once we received additional vaccine and supplies, we held a mass vaccination clinic in a local high school. That Saturday, mass vaccination efforts were hindered by the need to adhere to CDC guidelines regarding target populations for H1N1 vaccinations. People were turned away if they did not fit into one of the specific target groups, even if they were interested or had waited in line.

On December 9, 2009, the Georgia Department of Community Health announced that H1N1 vaccinations could be made available to the general public without group restrictions. Our new goal was to reach our local community quickly. We needed to bring the vaccine out of the clinics and to a population that might not normally visit a health clinic. We had ample amounts of vaccine to offer, and we were concerned that demand for the vaccine would decline significantly after the holiday season.

Actions taken to address the issue(s):

East Metro Health District rented a 1,400 square foot store space in the Mall of Georgia to offer H1N1 vaccinations during mall hours free of charge to the public over two weekends (December 12-13 and 18-19, 2009). This brought the vaccine to where people were already doing holiday shopping and targeted a different segment of the population. We offered nasal, injectable, and thimerosal-free versions of the H1N1 vaccination. If clients had insurance, we collected insurance information to bill for an administration fee; however, all clients were accepted without charge for the vaccine.

Our Public Information Officer created a press release and contacted television, internet, and newspaper media in the Atlanta media market to get the message to the public that East Metro Health District was offering H1N1 vaccinations at the mall to all populations for free. We emailed the press release to over 400 of our local partners (Emergency Management Agency, hospitals, schools, physicians, day care centers, universities, and health clinics). We asked the local partners to share or forward the press release widely to maximize word-of-mouth. We also used large A-frame signs to advertise our store location throughout the mall. The store front was marked with a large overhead sign and smaller A-frame signs reading "FREE H1N1 VACCINATIONS HERE." Greeters explained what our organization was offering and gave guidance on how to get into line.

One of the ways that we brought attention to our effort was by having a staff member dressed as Panda McFlu at our store front. The panda not only brought a great deal of attention to our store front, he was also a huge hit with our clients. Parents enjoyed their children's response as Panda entertained the crowd. If a child was upset, Panda was there to provide comfort. Panda also walked around the mall to raise awareness of our efforts and send clients toward our store space.

Our throughput was enhanced by passing out consent forms and Vaccine Information Sheets at the beginning of the line. This enabled clients to fill-out the forms while they waited in line. Staff consisted of health department employees and Medical Reserve Corps volunteers. Most of the staff had participated in numerous H1N1 mass vaccination clinics in the preceding weeks. Nurses and other staff members walked the line to answer questions about the vaccine and the consent forms. Staff members also verified that the forms were filled out correctly, and marked the forms regarding insurance status.

After reaching the front of the line, those with insurance were guided across the mall aisle into the store front. Insurance cards were copied at a station with copiers and attached to their consent forms. These people were filtered into a short holding line to wait for an open nursing station. Those without insurance were guided across the aisle and put into the holding line to be assigned to a nursing station.

Inside of our store space, we set up six nursing stations that could accommodate up to two nurses. One of those stations had extra space to accommodate large families, wheel chairs, or baby strollers. Another station was surrounded with privacy screens, should someone need privacy to take off their shirt for the vaccination. When possible, at least 2 stations were staffed with Spanish speaking nurses to meet the needs of our clientele. Spanish-speakers were also present in the lines and at the insurance stations.
A station was set up to allow nurses to pre-draw vaccine. The vaccine supply and refrigeration status were monitored by a nurse and our logistics chief. Support staff were used to pre-fill clip boards with consent forms and Vaccine Information sheets. Consent forms were printed with English on one side and Spanish on the other so that everyone in line received the same form. Runners brought clipboards to the line staff, refilled nursing supplies, and brought chilled vaccine to the nursing stations.

Staff worked either the full mall hours (around 12 hours) or one of two 6 hours shifts. In addition to district staff, we also had support from the local Medical Reserve Corps. Multiple changes were made on-the-fly due to bottlenecks or issues within the clinic design and flow. Fewer staff were needed on the second weekend because these changes increased efficiency.

Outcomes that resulted from actions taken:

East Metro Health District staff administered 5,900 H1N1 vaccinations in two weekends using a total of around 25 people per shift. Large numbers of clients (around 250/hr) can be handled by relatively few staff if staff are motivated and operations are streamlined. Wait times were always less than 15 minutes, even when the line was wrapped past multiple stores in the mall corridor. Many clients expressed amazement that the process was so quick and efficient. We drew such a large crowd that nearby stores reported having their best day of the season. Due to the heavy media coverage, word-of-mouth, and a creative but convenient location, we received clients from all over the greater Metro Atlanta area. One couple from Florida reported that they were visiting family for the weekend and heard about the vaccinations on the news. Many people did not know about the clinic prior to coming to the mall but decided to get vaccinated since it was convenient. After the first day, we had many people come by at the encouragement of family or friends who had been vaccinated on a prior day.

In the weeks following this clinic, public demand for the vaccine and media coverage of H1N1 related issues decreased significantly. Subsequent clinics offered by our district resulted in a much smaller turnout. Through this push, we reached a large portion of the community population that might not have come to a health department clinic during the week. This gave East Metro Health District positive exposure to clients who had never used Public Health services before. We used this positive opportunity to provide literature on our clinic services and locations. The successful event at the Mall of Georgia shows the efficiency of our staff and our creative clinic design in meeting the needs of the community. Most importantly, it reflects the strong partnership between our local health district, media and various partners in disseminating health-related information to our community and surrounding communities in a timely manner.